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We read with great interest the paper by Benito et al. (1) from the Brugada group. The authors confirm that important differences exist between men and women regarding the clinical picture and outcome in patients with Brugada syndrome. In general, in men the clinical picture appears more severe and the outcome is worse. Although this may seem presumptuous, we wonder if all subjects in this study truly had Brugada syndrome, in particular the women. From the paper, it reads as if the diagnosis “Brugada syndrome” is synonymous with the presence of a type-1 electrocardiogram (ECG) (coved-type, either spontaneously or after pharmacologic provocation with a sodium-channel blocker). It is not mentioned whether additional clinical features were required for the diagnosis. According to the consensus statement (2), in addition to a “Brugada ECG” (type-1 ECG), for Brugada syndrome to be definitely diagnosed at least 1 of the following clinical features is required: documented ventricular fibrillation or polymorphic ventricular tachycardia, a family history of sudden death at <45 years of age, coved-type ECGs in family members, inducibility of ventricular tachycardia with programmed electrical stimulation, syncope, or nocturnal agonal respiration. In other words, a Brugada ECG is not sufficient to diagnose Brugada syndrome, and this is a very important point both in clinical practice and in scientific studies. When applying the above criteria to the study by Benito et al. (1), some uncertainty remains. According to Table 2 in their paper (1), in women syncope was present “only” in 15%, aborted sudden cardiac death in 1%, a history of sudden cardiac death in 45%, and programmed electrical stimulation was performed in 81% with inducibility in 12%. If anything, these figures do not add up to 100%. Of note, there was also a difference in the baseline ECG; as many as 62% of the women had a normal or type-3 ECG as opposed to only 25% of the men. Obviously, in subjects in whom the diagnosis of Brugada syndrome is not firmly established, a mild clinical picture and a good outcome can be expected.

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